Provider Demographics
NPI:1811630031
Name:CHISM, EARL
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:CHISM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 16TH STREET
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0110
Mailing Address - Country:US
Mailing Address - Phone:415-476-5001
Mailing Address - Fax:
Practice Address - Street 1:550 16TH STREET
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0110
Practice Address - Country:US
Practice Address - Phone:415-476-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPTL12708208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program